Provider Demographics
NPI:1871842609
Name:DUBOIS, MALLORY SUE (RN)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:SUE
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:SUE
Other - Last Name:LAVIGNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:401 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-3628
Mailing Address - Country:US
Mailing Address - Phone:603-668-4111
Mailing Address - Fax:603-628-7757
Practice Address - Street 1:401 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03103-3628
Practice Address - Country:US
Practice Address - Phone:603-668-4111
Practice Address - Fax:603-628-7757
Is Sole Proprietor?:No
Enumeration Date:2012-09-07
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH066476-21163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health